Reviewing asthma and anxiety

Patient satisfaction with different asthma-training variants

OBJECTIVE

Information on patient satisfaction with professional health care delivery in asthmatics is rare, and the question as to how asthma education programmes affect such satisfaction has not yet been addressed.

METHODS

This multi-centre study investigated three different variants of an asthma education programme for adults. Patients participated either in variant B (basic training with teacher-directed presentation, two 90 min sessions), variant C (comprehensive training, four sessions), variant D (including additional psychological components, minimum five sessions), or variant E (equivalent to B in outpatient context). At the end of the training the perceived satisfaction with the programme and reported personal benefit were assessed by means of a new inventory that was developed.

RESULTS

The sample comprised N = 320 patients (n = 244 inpatients and n = 76 outpatients) ranging in age from 18 to 80 years (M = 46.3 years). The average total score for educational satisfaction of all participants was 8.0 (maximum score = 10). Choice of topics was judged particularly positive (M = 8.58), followed by the structure of training/setting-conditions (M = 8.0). The perceived personal benefit from the training was evaluated less positively (M = 7.32). When comparing the programme variants, patients' average satisfaction tends to increase with the extent and intensity of the training offered. Outpatients showed significantly less satisfaction in contrast to inpatients. Inpatients' satisfaction with the three variants increased with extensiveness and intensity of the training, while the contrast of between-group comparisons (B-C, B-D and C-D) was significant.

CONCLUSION

Assessment of the patient's view of health care services should complement standardised evaluation methods, especially in multi-intervention rehabilitation programmes.

PRACTICE IMPLICATIONS

Rehabilitation-specific diagnostic measures should be developed and validated in order to better assess patients' satisfaction and training efficacy from the patient's perspective. Further study is recommended on how far individualised training measures might increase subjective benefit.

[Therapeutic education in asthma management]

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.

Anxiety and panic fear in adults with asthma: prevalence in primary care

Background

Patients may find it difficult to distinguish between the symptoms of anxiety and those of asthma. Findings are equivocal on whether there is a specific link between anxiety and asthma. The aims of this study were to i) to identify the prevalence of anxiety, depression and panic fear in adults with asthma compared with that of the general population ii) to investigate whether there is a specific relationship between asthma and anxiety.

Methods

An epidemiological survey of 872 adults with a diagnosis of asthma identified from six General Practices in Sheffield, England. Community postal survey using self-completion questionnaire.

Results

The response rate was 59%. People with asthma had higher mean Hospital Anxiety and Depression Scale (HADS) anxiety scores than UK norms with a higher proportion above the clinical cut-off. Mean HADS depression scores were significantly higher than UK norms and norms for a general population sample of people registered with the same practice. These effects were age-related with the relationship between asthma and psychological distress most marked over the age of 45. The prevalence of asthma-specific panic fear was 15.7%.

Conclusion

A significant minority of people have high levels of panic fear (as measured by the Asthma Symptom Checklist) associated with asthma. However, in adults with asthma there is also high prevalence of both generalised anxiety and depression (as measured by the HADS), suggesting that the link of anxiety to asthma may be part of a broader relationship between psychological distress and chronic disease rather than a specific one.

Verhaltensmedizinische Behandlungsstrategie der Fibromyalgie

The etiology of fibromyalgia as a chronic disease is still unexplained. This article gives an overview of the newest treatment methods of behavioral medicine of the fibromyalgia syndrome with regard to the state of research of etiology and diagnosis of this disease. Methods such as operant conditioning, cognitive-behavioral approaches, patient education and relaxation methods are discussed.

Evidence-based hypnotherapy for asthma: a critical review

Asthma is a chronic disease with intermittent acute exacerbations, characterized by obstructed airways, hyper-responsiveness, and sometimes by chronic airway inflammation. Critically reviewing evidence primarily from controlled outcome studies on hypnosis for asthma shows that hypnosis is possibly efficacious for treatment of symptom severity and illness-related behaviors and is efficacious for managing emotional states that exacerbate airway obstruction. Hypnosis is also possibly efficacious for decreasing airway obstruction and stabilizing airway hyper-responsiveness in some individuals, but there is insufficient evidence that hypnosis affects asthma's inflammatory process. Promising research needs to be replicated with larger samples and better designs with careful attention paid to the types of hypnotic suggestions given. The critical issue is not so much whether it is used but how it is used. Future outcome research must address the relative contribution of expectancies, hypnotizability, hypnotic induction, and specific suggestions.

Mental disorders among adults with asthma: results from the World Mental Health Survey

OBJECTIVE

Our objectives were (a) to determine which common mental disorders are associated with asthma in the general population after controlling for age and sex, and (b) to assess whether the associations of mental disorders with asthma are consistent across diverse countries.

METHOD

Eighteen population surveys of household-residing adults were carried out in 17 countries (N=85,088). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0, a fully structured diagnostic interview. The disorders considered here are 12-month anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, posttraumatic stress disorder and social phobia), depressive disorders (dysthymia and major depressive disorder) and alcohol use disorders (abuse and dependence). Asthma was ascertained by self-reports of lifetime diagnosis among a subsample (n=42,697).

RESULTS

Pooled estimates of age-adjusted and sex-adjusted odds of mental disorders among persons with asthma relative to those without asthma were 1.6 [95% confidence interval (95% CI)=1.4, 1.8] for depressive disorders, 1.5 (95% CI=1.4, 1.7) for anxiety disorders and 1.7 (95% CI=1.4, 2.1) for alcohol use disorders.

CONCLUSION

This first cross-national study of the relationship between asthma and mental disorders confirms that a range of common mental disorders occurs with greater frequency among persons with asthma. These results attest to the importance of clinicians in diverse settings being alert to the co-occurrence of these conditions.

Klinische Jugendpsychologie

Zusammenfassung: Klinische Jugendpsychologie beschäftigt sich mit auffälligen Entwicklungsverläufen im Übergang zum Erwachsenenalter. Problematische Entwicklungen stellen Rauchen und Alkoholgebrauch/-missbrauch dar. Besondere Anforderungen und Belastungen ergeben sich aus körperlich-chronischen Erkrankungen. Psychische Reaktionen auf Anforderungen und Belastungen äußern sich vielfach geschlechtsspezifisch.

Interference of psychological factors in difficult-to-control asthma

BACKGROUND

Most patients with asthma can be controlled with suitable medication, but 5-10% of them remain difficult to control despite optimal management.

OBJECTIVE

We investigated whether patients with difficult-to-control asthma (DCA) or controlled asthma (CA) differ with respect to psychological factors, such as general control beliefs on life events.

METHODS

DCA was defined as an absence of control despite optimal management. Recent control was measured using the Asthma Control Questionnaire. General control beliefs were investigated using a Locus of Control scale (LOC).

RESULTS

Patients with DCA had a significantly higher external LOC as compared to patients with CA (P=0.01). In the DCA group, the hospital admission rate was highly significant in association with the external LOC (P=0.004) as compared to the internal LOC trend.

CONCLUSION

This study showed that patients with DCA had different general control beliefs which might have hampered their management and interfered with their therapeutic adherence. The present findings could enhance management of DCA in a clinical setting.

Anxiety, panic and adult asthma: a cognitive-behavioral perspective

A review of previous research suggests increased probability of the prevalence of anxiety disorders, and particularly panic disorder and panic attacks in patients with asthma, as compared to a normal population. Research also indicates significant levels of co-morbidity between asthma and anxiety as measured on dimensional scales of anxiety and panic. Clinical anxiety and panic manifestations affect symptom perception and asthma management through the effects of anxiety symptoms such as hyperventilation, and indirectly through self-management behavior and physician response. However, there is limited data on the impact of anxiety co-morbidity on asthma quality of life. Some studies indicate that individuals with co-morbid asthma and anxiety or panic report worse asthma quality of life both in general and in relation to their symptomatology, being limited in their daily activities, in response to environmental stimuli and in regard to feelings of emotional distress. Cognitive-behavioral therapy (CBT) is an effective and empirically supported treatment of choice for anxiety disorders and panic attacks. However, standard CBT protocols for anxiety and panic may need to be specifically targeted at improving asthma outcomes. Also, asthma research literature is lacking in randomized controlled trials applying CBT to patients with co-morbid asthma and clinical anxiety manifestations. Trials evaluating CBT interventions in individuals with clinical anxiety manifestations and asthma may provide evidence of these interventions as an effective adjunct to improve asthma management and control.

Major depression and the use of electroconvulsive therapy (ECT) in lung transplant recipients

The purpose of this study is to describe the potential risks and benefits of electroconvulsive therapy (ECT) for treatment of depression in lung transplant recipients. The authors performed a record review of depressed patients who underwent lung transplantation at Johns Hopkins Hospital and evaluated their treatment, including ECT. In 9 years, 131 lung transplants were performed, and four patients had been diagnosed with major depression. Of those, two were candidates for ECT, and one received it. This patient's depression did abate with ECT. ECT, an effective treatment for depression, remains a treatment method of choice for depression in the posttransplant population.

Associations of self-reported anxiety symptoms with health-related quality of life and health behaviors

BACKGROUND

Anxiety disorders affect approximately 19 million American adults annually and have been associated with impaired health-related quality of life (HRQOL), an increased rate of adverse health behaviors, and poor outcomes related to chronic illness in studies conducted in clinical populations. Our study was designed to examine the association of self-reported anxiety symptoms with HRQOL and health behaviors among a representative sample of US community-dwellers.

METHODS

Data were obtained from the Behavioral Risk Factor Surveillance System,an ongoing, state-based, random-digit telephone survey of the noninstitutionalized US population aged > or = 18 years. In 2002, HRQOL measures were administered in 18 states and the District of Columbia.

RESULTS

An estimated 15% of persons reported frequent (> or = 14 days in the past 30 days) anxiety symptoms. After adjusting for frequent depressive symptoms and sociodemographic characteristics, those with frequent anxiety symptoms were significantly more likely than those without to report fair or poor general health (vs. excellent, very good, or good general health), frequent physical distress, frequent activity limitations, frequent sleep insufficiency, infrequent vitality, frequent mental distress, and frequent pain. In addition, they were more likely to smoke, to be obese, to be physically inactive, and to drink heavily.

CONCLUSION

Given their association with impaired HRQOL and adverse health behaviors, our results suggest that assessment of anxiety symptoms should be a facet of routine standard medical examinations.

Asthma, ear problems, and dental anxiety among 6- to 8-yr-olds in Denmark: a population-based cross-sectional study

The aim of this study was to examine the association between asthma, ear problems, and dental anxiety in children in a population-based cross-sectional study. The population included four municipalities in the County of North Jutland, Denmark, in 2001. A total of 1235 children aged 6-8 yr, and their parents, were identified. Data were obtained from a prescription database, from parental-answered questionnaires, and from dental records. Children with asthma were defined as children that had received prescriptions for both inhaled beta2-agonists and corticosteroids during the past year. Data on ear problems and dental anxiety were obtained from the questionnaires. Dental anxiety was measured using the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS). Use of asthma-drugs was associated with dental anxiety (odds ratio = 1.70; 95% confidence interval 0.90-3.22). A history of often ear problems was also associated with dental anxiety (odds ratio = 1.83; 95% confidence interval 1.20-2.80). It is concluded that asthma and ear problems may be risk factors for dental anxiety in children.

Anxiety symptoms in allergic patients: identification and risk factors

OBJECTIVES

Multiple relationships between anxiety, allergic symptoms, and treatment difficulties have been observed. The aim of the present study was to estimate the prevalence of anxiety disorders in outpatients with various allergic diseases, to identify diagnostic cues or possible risk factors, and to test the usefulness of self-administered questionnaire screening at the allergy clinic.

METHODS

Six hundred forty-six (646) consecutive patients with rhinoconjunctivitis (59.3%), asthma (26.8%), or "other" allergy (13.9%), aged 16 to 65 years, completed self-administered questionnaires in six outpatient allergy clinics; 60 of the respondents also participated in structured psychiatric interviews. Anxiety was measured with the Spielberger State-Trait Anxiety.

RESULTS

According to the interviews, STAI-T > 52 predicted with 86% accuracy a current psychiatric diagnosis, without differentiating between anxiety and depression. Using this threshold, the rate of anxiety and/or depressive disorders is estimated as 19% (95% CI: 15.9-22.1) in our unselected allergic outpatient sample; 46% of these patients never received any psychopharmacological treatment, indicating that anxiety related disorders are underdiagnosed and undertreated. Risk indicators were female gender; asthma; perennial symptoms; sleep problems; nonspecific allergy triggers like strong emotions; stressful situations; and considerable limitation in everyday activities attributed to the allergic symptoms.

CONCLUSIONS

Our findings confirm a high rate of anxiety and/or depressive disorders in patients visiting the allergy clinic. Self-administered questionnaires such as STAI-T provide reliable help for the identification of these frequent psychiatric problems.

Self-hypnosis for anxiety associated with severe asthma: a case report

BACKGROUND

Management of asthma can be complicated by both medical and psychiatric conditions, such as gastroesophageal reflux, chronic sinusitis, and anxiety. When symptoms of asthma are interpreted without regard to such conditions treatment may yield a suboptimal outcome. For example, anxiety-associated dyspnea, tachypnea, and chest tightness can be mistakenly interpreted as resulting from an exacerbation of asthma. Medical treatment directed only for asthma may thus lead to overuse of asthma medications and increased hospitalizations.

CASE PRESENTATION

The described case illustrates how a systemic steroid-dependent patient with asthma benefited from receiving care from a pediatric pulmonologist who also was well versed in the diagnosis and treatment of anxiety. By using self-hypnosis, the patient was able to reduce her dependence on bronchodilators. Following modification of her medical therapy under supervision of the pulmonologist, and regular use of hypnosis, the patient ultimately was weaned off her systemic steroid therapy.

CONCLUSIONS

This report emphasizes that anxiety must be considered as a comorbid condition in the treatment of asthma. Self-hypnosis can be a useful skill in the treatment of a patient with anxiety and asthma.

Eine Skala zur Erfassung von elterlichen Selbstwirksamkeitserwartungen im Umgang mit dem Asthma ihres Kindes

Zusammenfassung. Theoretischer Hintergrund: Die wahrgenommene Selbstwirksamkeit wird als wichtige Erklärungs- und Vorhersagevariable zur Umsetzung von Behandlungsmaßnahmen erachtet. Messinstrumente zur Erhebung der Selbstwirksamkeit bei Eltern asthmakranker Kinder fehlen. Fragestellung: Entwicklung und Validierung einer Selbstwirksamkeitsskala, die die Erwartungen der Eltern bzw. Bezugspersonen im Umgang mit asthmaspezifischen Anforderungssituationen erfassen soll. Methode: 188 Eltern asthmakranker Kinder beantworteten diese Skala. Zur Konstrukt- und Kriteriumsvalidierung wurden die “allgemeine Kompetenzerwartung“, der “Paediatric-Asthma-Caregivers-Quality-of-Life-Questionnaire“, die gesundheitsbezogene Lebensqualität (SF-12) ebenso wie Krankheitsparameter und -indikatoren erfasst. Ergebnisse: Die psychometrischen Itemkennwerte liegen im annehmbaren Bereich; die interne Konsistenz ist zufriedenstellend; Veränderungen der Selbstwirksamkeit ergeben sich im Verlauf von Interventionen. Schlussfolgerung: Die Korrelationen mit konstruktfernen und -nahen Fragebögen unterstützen deren Validität. Die Skala kann in klinischen Studien die Veränderung des Selbstwirksamkeitserlebens abbilden.

Coping as a mediator of psychosocial impediments to optimal management and control of asthma

Adherence to asthma medication regimens by asthma patients is often poor and contributes to the continued and substantial burden of asthma in the community. There is evidence of increased rates of behavioural problems, anxiety and depression in people with moderate-to-severe asthma and these factors may interfere with adherence and contribute to poor asthma control. An alternative explanation is that the relationship between feelings of anxiety and depression, and adherence to the treatment regimen may be more accurately predicted from the coping styles used, rather than the experience of asthma itself. The objective of this paper was to review evidence for associations between coping strategies used by asthma patients, asthma management and health outcomes. The Medline and PsychInfo databases were searched for articles containing the terms "asthma" and "coping". Patients with asthma tended to use different strategies for coping with stress and illness compared to healthy participants and individuals with other chronic illnesses. Emotion-focussed coping strategies such as denial were commonly used by patients with poor medication adherence, those who attended emergency departments for asthma, were admitted to hospital for asthma, or suffered near-fatal asthma attacks. Interventions to improve coping strategies have been effective in reducing symptoms and psychological distress. The availability of coping resources to patients and/or their caregivers and the coping strategies that are used are likely to mediate the influence of psychosocial factors on the management of asthma. Further studies exploring the ways in which individuals cope with asthma will improve our understanding of the mechanisms linking psychological and social status to asthma morbidity and mortality.

Inhaled corticosteroids (budesonide): the cornerstone of asthma therapy--what are the options?

The clinical value of corticosteroids in treating asthma has long been recognised. Major advances in the use of these drugs came with the introduction of inhaled corticosteroids (ICS) and the recognition that even mild asthma has an inflammatory component. ICS are now considered as first-line therapy in all asthma treatment guidelines. Over the past decade there has been clarification of the dose-response relationship with ICS and confirmation of the general long-term efficacy and safety of these drugs in both adults and children. Recent work has focused on simplifying dosing regimens and investigating flexibility of dosing. Moreover, ICS can be used in combination with other agents such as long-acting inhaled beta(2)-agonists to provide effective asthma control in patients with persistent asthma not adequately controlled on ICS alone. Thus, ICS remain the cornerstone of modern asthma therapy.

Living with a variable disease

Asthma is a variable disease which, when not fully controlled, may leave the patient with a sense of bewilderment, fear, anger and a loss of many 'normal' activities of daily living. The reasons for these fears range from the concern of having an asthma attack to concerns about taking medications, perhaps especially steroids. Complex treatment regimens and a lack of understanding by the patient of their asthma may lead to denial and a reduction in adherence to medication resulting in poor treatment outcomes. Patients' lack of understanding may originate from poor communication between patient and physician. Improved communication and ensuring that all of the patient's questions are answered, as well as simpler treatment regimens may improve asthma control. Detailed, written personal asthma action plans should act as a foundation for building good relationships between doctor and patient and enhance adherence. Simplifying treatment regimens, such as having an inhaled corticosteroid and a long-acting, beta(2)-agonist in a single inhaler, used in conjunction with these personal asthma action plans, should provide a therapy that enables patients to be in control of their asthma without having to live in fear of their illness.

Perceptions and attitudes of adolescents with asthma

BACKGROUND

Psychosocial factors can limit one's ability to effectively manage asthma. This can result in asthma morbidity that limits quality of life. While self-perceptions of asthmatic children and parents have been studied, less is known about self-perceptions of inner-city adolescents with asthma.

OBJECTIVE

To examine perceptions and attitudes to treatment among inner-city adolescents with asthma.

DESIGN/METHODS

We conducted a multistaged stratified sample survey at a high school located in the Bronx, NY. First, an asthma-screening survey was administered to 3800 registered students. Then, we identified a subset of 200 children with the most positive screening results for asthma. Next, a 32-item self-completion questionnaire was administered to this cohort. Students were surveyed regarding severity of asthma, perceptions and attitudes, and demographic information. Differences in proportions were tested by Chi-square analyses. Pearson rank-order correlation and multiple logistic regression were used to assess the relationship between perceptions and attitudes to self-treatment.

RESULTS

A total of 160 (80%) students participated. Mean age was 15.7 years. Of the respondents, 63% were female. 68% were Hispanic, 26% were African American. 33% had weekly symptoms, and 14% had daily symptoms. Additionally, 41% did not know the name of their asthma medicine. Only 38% reported bringing an "asthma pump" when leaving the house. While 70% reported feeling in control over their asthma symptoms, 63% reported feelings of anxiety and 39% could remember a time when they felt like they were going to die from asthma. Subjects who reported feeling in control over their asthma were more likely to take an asthma pump with them when leaving the house (r = 72, p = 0.004). Only 39% had disclosed their asthma to their friends, and 29% felt embarrassed about having an asthma attack in front of their friends. Subjects who felt embarrassed about their asthma were significantly less likely to take their asthma pumps with them (r = 0.98, p < 0.001) and less likely to use their medications in front of their friends (r = .87, p < 0.001).

CONCLUSIONS

Adolescents in this study reported feelings of anxiety, fear, and embarrassment about their asthma. Feelings of control over asthma symptoms were associated with positive attitudes toward self-treatment, while embarrassment was correlated with negative attitudes. These findings have implications for counseling adolescents with asthma about self-management strategies.

Relationship between separation anxiety disorder, parental panic disorder, and atopic disorders in children: a controlled high-risk study

OBJECTIVE

To test the hypotheses that rates of atopic disorders are elevated in offspring of parents with panic disorder (PD) and in children with separation anxiety disorder (SAD).

METHOD

Rates of atopic disorders were assessed in 343 offspring (aged 6-17 years) of parents with PD, nonpanic psychiatric disorders, and no psychiatric disorder. Lifetime history of atopic disorders was determined by parental responses to a clinician-administered questionnaire assessing medical treatment for asthma and allergies. Logistic regression analyses assessed the association between atopic disorders and parental PD, and between atopic disorders and probable or definite childhood SAD. Analyses controlled for age, sex, socioeconomic status, and treatment for other medical illnesses.

RESULTS

Increased rates of atopic disorders were found in offspring of parents with PD (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 1.27-5.16, p = .009) and in children with SAD (OR = 2.71, 95% Cl = 1.22-6.03, p = .015). Associations remained significant when both parental PD and SAD were included in the model, suggesting that each contributed independently to increased rates of atopy. The interaction of parental PD and child SAD was not significant.

CONCLUSIONS

Atopic disorders in children are associated with parental PD and with childhood SAD. Results do not appear to support that having both childhood SAD and a parent with PD confers increased risk for atopic disorders above and beyond either condition alone.

Psychiatric issues in pulmonary disease

This article has attempted to provide an overview of the clinical literature regarding the psychological issues facing patients with pulmonary disease, depending on when the illness begins in the life span, because different developmental tasks are disrupted. Patients must contend with side effects of medication that may mimic or exacerbate psychiatric disorders. The main drug interactions for psychiatrists to be aware of in this patient population occur between rifampin, or theophylline and psychotropic medications. In lung transplant recipients on cyclosporine therapy, the antidepressant drug nefazadone may cause increased cyclosporine levels. Psychiatrists must be aware of the risks, benefits, and survival statistics; educate patients; and ascertain whether the patient is competent to make medical decisions regarding treatment procedures.

Does the vagus nerve mediate the sixth sense?

Can sensations originating from the internal environment modulate attitude and behaviour? Can the feedback about the operation of the viscera provide a calming and relaxing influence? Information from the chest and abdomen is delivered continuously by the vagus nerve, the largest visceral sensory nerve in the body. Because various 'stress-related' diseases can be associated with impaired functions in sensory vagal fibres, a better understanding of how sensory vagal information is processed in the CNS might offer new strategies for the treatment and/or prevention of several disorders, including 'drug-resistant' forms of eating disorder, anxiety, chronic depression and epilepsy. A neuronal circuitry that has been suggested by experimental data to mediate sensory vagal inputs to those brain areas that are involved in the generation of 'stress-related' disorders is outlined.